Periodic Personal Care Plan (PCP) - Page 1 of 2 WPF GDN 05.0700 (01/2009) RCW 11.92.043, .050 Superior Court of Washington County of Clark In the Guardianship of: , Incapacitated Person No. Periodic Personal Care Plan (PCP) The [ ] Full [ ] Limited Guardian of the Person, respectfully submits the following Personal Care Plan: 1. Custody and Residence of Incapacitated Person The Incapacitated Person is now years of age. He/She presently resides at (name of facility, if applicable, and address): . The Guardian believes that he/she is receiving satisfactory care, and should continue to reside there. 2. Description of Services or Programs Incapacitated Person Receives The Incapacitated Person receives the following services or programs: . 3. Physical and Medical Status and Need of Incapacitated Person The physical and medical status and needs of the Incapacitated Person are as follows: . 4. Mental and Emotional Status of Incapacitated Person The mental and emotional status of the Incapacitated Person is as follows: . American LegalNet, Inc. www.FormsWorkFlow.com Periodic Personal Care Plan (PCP) - Page 2 of 2 WPF GDN 05.0700 (01/2009) RCW 11.92.043, .050 5. Description of Functional Abilities of the Incapacitated Person The following is a description of the Incapacitated Person222s abilities to perform and/or assist in the activities of daily living. . 6. Guardian222s Specific Plan for Meeting the Identified and Emerging Personal Care Needs of the Incapacitated Person The Guardian222s specific plan for meeting the identified and emerging personal care needs of the Incapacitated Person is as follows: . 7. Contact Information for Facility or Home of Incapacitated Person, Guardian and Standby Guardian Facility/Home Contact Guardian Standby Guardian Full Name Mailing Address City, State, Zip *Telephone Number I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Signed at (city) , (state) on (date) . Signature of Guardian Print Name of Guardian [ ] WSBA No. [ ] CPG# Address City, State, Zip Code *Telephone/Fax Number Email Address *If you do not want your personal phone number on this public form, you may list your telephone number on a separate form which may be available to parties and the court, as well as its staff and volunteers, but will not be made available to the public. Use Form WPF GDN 03.0100, Guardianship Confidential Information form (Telephone Numbers), for this purpose. Note: Do not attach records produced and signed by a health care provider to this form. American LegalNet, Inc. www.FormsWorkFlow.com